Health At Every Size: choice or coercion?

I wanted to address was something I read a while back, and have been sort of turning over in the back of my head ever since. [Via The Fat Girl.]

These are the fat acceptance zealots — using fat acceptance and ‘in your face’ fat imagery and messages in order to shock the world into accepting their fat as meaning they are valid, worthy and ultimately just as healthy as the next person.

“And really fat people are valid and worthy, but as healthy as the would be if their hearts weren’t beating much harder in order to accommodate an extra 100lbs?

“No — this simply cannot be.”

–Weighted Long Enough

This is the writing of a woman who was once passionately involved in fat acceptance. Presumably, she still believes in basic tenets like, you know, appearance-based discrimination is wrong. But she got to a point where she felt her fat was detrimental to her health.

Now, I wouldn’t presume to argue with a person about their own experience, except to say that I believe directly addressing comorbidities associated with fatness is probably more effective than addressing the fatness itself, given that there are precious few (read: NO) permanent, safe methods of fat reduction.

But still, a person is allowed to be the expert on their own experience. If she feels that fat was causing her health problems, who the hell am I to contradict her?

This is where I believe Health At Every Size connects with the fat movement. The fat movement, as I see it, is primarily about politics and human rights, and well it should be. These are the critical, the most important, factors determining our experiences as fat people. But because fat is inextricably bound up in matters of health, at least from the perspective of our oppressors, the HAES component is a critical tangent of our movement.

See, the thing is, people who are involved in fat acceptance don’t always seem to fully understand HAES, and this concerns me. It concerns me because it is a useful tool that many of us seem content to toss by the wayside. This woman is a prime example of not understanding the basic structure of the HAES philosophy…the first being that “Health At Every Size” means health at every size for the population, not necessarily the individual.

If you accept the theory of set-point, as many fat acceptance advocates do, then you realize that an individual body has a preferred level of adiposity, for which a handy (though imperfect) proxy is body weight. This not only means that maintaining a weight lower than set-point is not good for you, but also that maintaining a weight much higher than your body’s natural set-point range is also not good for you.

The thing is, despite what the BMI dorks seem to think, set-points, or body weights, or body compositions, naturally come in a wide variety. I like to think of this as one way our species protects itself against extinction by one poorly-timed famine, epidemic, or ice-age. If all our bodies operated identically, the human race could easily be wiped out in one fell swoop, because we’d all react in exactly the same way to dramatic environmental changes.

So there is variety in size. There is variety in nutrient requirements as well…not only for kcalories, and macronutrients like fat, protein, and carbohydrates, but also for vitamins and minerals. Now I know those RDAs and the popular multivitamin supplements and the Food Guide Pyramid and everything seem to suggest that we all have the same requirements, dependent on things like age and sex, but it’s not so. Those things are basically educated guesses on how we can catch most of the population, within its wide range of requirements, so that nutrient deficiencies are no longer widespread. There was a time when things like scurvy and rickets were near-epidemic, so the usefulness of these tools can’t be overstated. But they do not represent some magical, unequivocal number that super-smart scientists have determined to be the perfect amount of X nutrient for everyone in the whole world.

If you doubt this, I would like to turn your attention to the development of the DRIs, which are, basically, a more complex and comprehensive form of the RDAs. There were huge debates, for example, over the recommended intake of calcium. Calcium! A nutrient we all take for granted as being a set-in-stone, God-given prescription for strong teeth and bones! Well, the goddamn scientists argued so much over the RDA for calcium that they never came to consensus. So, yes, you read that right, there is no RDA for calcium at this time. Instead, they came up with a rough guesstimate (the AI), from which specific recommendations cannot be extrapolated.

Okay. Phew. Sorry for the Nutrition 101 lecture. I just wanted to illustrate my point that, if we can’t even come up with solid numbers for the entire population on something as basic as calcium, why do we assume that ideal weight can be so easily established?

It can’t. Just as it is not logistically feasible to thoroughly test and document the nutrient requirements of each individual across the entire population, it is logistically infeasible, and as yet IMPOSSIBLE (since we are nowhere near understanding all of the complex mechanisms that influence body weight), to determine every single person’s healthiest weight. For practitioners of the HAES model, the definition of ideal weight is this: the weight you maintain when you are eating nutritiously and getting adequate physical activity. Not some arbitrary, shame-inducing number on a goddamn table picked out by a bigot like Walter Willett. Sorry, but for all you BMI-lovers out there — them’s the fucking breaks.

So, back to this woman. Is it possible that she maintained a weight that was above her own healthiest weight? YES. Does this mean that anyone else maintaining the same weight and body composition at similar height, age, and gender is also above their healthiest weight? NO.

Health at every size, as I have said approximately 7,386 times on this journal, does not mean that one individual can be healthy at every size. Cause you can’t. You’ve got a basic range, and the range may shift a bit during different stages of life, but you cannot run up and down the huge spectrum of possible body weights, like a pianist running his hands over the keys from lowest to highest, and expect to be perfectly healthy at each step.

It is perfectly possible that, by an individual definition, this woman was ‘overweight.’ The problem, though, with focusing on weight, even if it does prove to be causing health problems for a person (and this is rarely, if ever, proven), is that not only is there no way of predetermining an individual’s ideal weight, there ain’t much we can do about the weight anyway. Weight-loss treatments, from drugs to diets, are dismal failures. GI surgeries are risky and do not have a lot of long-term research to back them up (I won’t even mention the anal incontinence, or possible vitamin deficiences that can cause irreversible neurological damage. Oh wait, I just did. Sorry.) Even people trying to gain weight have some difficulty.

So it’s a bit of a bind, isn’t it? And even if someone buys fully into the political aspects of fat liberation (there, I said it, fat liberation), the health argument is just sitting there, waiting for them to have a bad day, or to get tired of being fat (which is a very real possibility in this culture), or to get sick in a way that a doctor would readily attribute to ‘obesity.’ Under these circumstances, it is very easy to see why even an ardent supporter of the politics of fat liberation might go and do a thing like have weight-loss surgery, or start a reducing diet, or take the newest FDA-approved fat-person extermination pill — I mean, ‘obesity treatment’ — and maybe start to side, just a little, with the attendant propaganda. Because cognitive dissonance is a bitch.

This is the where Health At Every Size becomes not only a useful tangent to fat liberation, but an essential component.

Listen: there is an alternative. We need not be extremists on either end of the spectrum of fattitude — one being the end that says “I am healthy no matter what” and the other being the end that says “I’ll take the Roux-en-Y with a side order of Meridia” — because, all-too-often in my experience, two extreme ends of any spectrum eventually meet in the same, frighteningly psychotic person. Like radio shock-jocks who go from an ultra-liberal upbringing to ultra-conservative vitriol in the brief time it takes to experience one adolescent disillusionment. Like the woman who writes about being “involved in the fat acceptance movement as a way to stay in an illusion that one can be extremely fat and healthy.”

Thing is, there are extremely fat and healthy people out there. That’s how the fucking bell curve works. No, you cannot be healthy at every size. But we can. Here’s how:

You eat well. This is not a moralistic determination, nor is it the same from person to person. There are general suggestions that most people can safely follow, but the most important is to learn to listen to your gut. Try to resuscitate the cues that a lifetime of dieting and an eating-disordered culture have probably killed. If you can’t do it on your own — and many can’t; it’s hard — get someone to help you. Size-friendly therapists and dietitians exist, and many of them believe in an empowering philosophy of health promotion, which in English means: you get to make your own choices. You get to figure out what is best for you. Because even scientists can’t tell you how much goddamn calcium you need.

You move well. This is also hard to figure out, and I’m currently doing battle with it myself. Kell has some good ideas. Like we all have an appetite for food, I think we all have an appetite for movement. Think back to the way you might’ve played as a kid, the times you got restless from sitting still for too long. Try to remember a time when being sweaty and out of breath meant you were having a fucking awesome time (if you’re lucky enough to have such memories.) Think back on those times, and try to come up with creative ways to have fun now. REAL fun, like the kind of fun you had when all you needed was a hot day and a sprinkler in the yard, or a jump-rope, or a piece of chalk and a stretch of concrete. When did adult movement become so boring and medicinal? Who says you need to have ‘proper footwear’ or a gym membership or all sorts of ugly spandex clothing in order to get a little hot and sweaty? If you’re into that kind of thing, cool; you have that many more options than the rest of us who hate all that shit. And if you hate it, take heart: so do I. But I won’t be disingenuous and pretend that physical activity has no bearing on our well-being. Neither will I deny that it’s more than possible to go out and find ourselves a bit of fun.

Third, you learn to deal with your body. Whatever size it’s at, whatever health conditions you might be facing, whatever colour it is, however big your butt is, or small your tits are, or anything. You take what God fucking gave you, and you make the best of it. You do the treatment for any health problems by focusing directly on the problem itself, not by buying into the cultural fantasy that, if you lose weight, you’ll magically lose any physical and/or mental illnesses along with it.

By doing this, your body is going to change in whatever way is best for it to change. You don’t get to control that. It might mean gaining weight, in the form of fat or muscle, and feeling self-conscious. But we have tools to deal with that, because that is what this whole movement is about: creating a society where people of all sizes can feel reasonably welcome.

It might mean losing weight, and you might feel guilty, like you’re betraying your fat liberation buddies. But you’re not betraying anyone. A real betrayal would be to go and swallow shit like “I wanted to believe I could be as healthy as a person whose weight didn’t literally drag them down. This was my greatest lie – a lie that allowed me to get more and more fat, until I’ve now reach the point of do or die.” Betrayal would be to believe that, in order to be healthy, you must first focus on changing your body to a socially-enforced ideal…in order, presumably, to become ‘deserving’ of proper health- and self-care. Betrayal would also be to totally deny the fact that eating and moving well will have a positive impact on your health, and that, if you want to, you deserve those things as much as anyone else.

Most likely, no matter how your weight changes, your basic health indicators are going to improve. Your blood pressure is probably going to improve, as well as your blood cholesterol, and your ability to use insulin and regulate your own blood sugar. These are much more accurate proxies for health than body size could ever be. And if things get worse, it’s a sure sign that something else is going on and you need to see a doctor. But for most people, you can bank on the fact that eating and moving well and treating your body with respect is only going to make things better, whether or not you get bigger or smaller in the process.

Listen: as surely as we are oppressed by systematic external discrimination, we collude in our own oppression by not demanding the care we deserve from health professionals, and by not caring for ourselves in the way we deserve. And don’t you believe for a MINUTE that you have to submit to ‘their’ idea of health and self-care, or the health meritocracy. First and foremost, all of this is a choice. It is optional. But in order for that choice to even exist, we have to have access to good information, and we have to really believe that we deserve to be cared for. I have a sneaking suspicion that an internalized sense of inferiority drives a lot of our rebellion against ideas of self-care and health at every size. And I totally understand. I get panicky, too, when I entertain ideas of ‘making healthy choices’ and what-not because, more often than not in our deranged, pathological society, ‘making healthy choices’ is code for ‘submitting to coercion.’ I know. I know. But we can’t let the difficulty of the fight let us stop fighting it.

There are size-friendly health professionals out there. There are dietitians and therapists and doctors in a number of specialties who are on our side. We definitely need more of them, and that’s another thing we’re working on, but we should be taking advantage of the ones we’ve got. (Check out Stef’s Fat Friendly Health Professionals page.) We also need better resources for general information on health and nutrition — in print, on the internet, on TV — stuff that comes from a size-positive perspective (hell, even a size-neutral perspective would be an improvement over what we’ve got now.)

Pattie pointed out that a lot of the HAES terminology is being co-opted by forces that are anything but size-friendly. This scares me, and I think one of the reasons they’ve been able to do this is that HAES has not yet come into its own. One of the things we’ve got to fight for is to make HAES work, and work in the way we want it to. We can’t let it revert into yet another health-fascist approach that’ll only find creative new ways to blame and marginalize people in the name of health.

Pattie also talked about how the personal is political.” With the way things currently are, what could be more political than for people to stand up, demand quality health-care, and to make truly free and informed choices about their health, regardless of what size they are? In a true HAES framework, this would never result in dividing us into ‘good people’ and ‘bad people.’ It would simply give people of all sizes the information and support they need to make real choices — something we don’t currently have, since most of our resources are hopelessly tainted by their association with “Brand Thin” — and its mandate would be to then respect those choices, whether they might be classified by the majority as ‘healthy’ or not.

If we’re fighting a war here (I’ll indulge in some militaristic language, since everyone else seems so eager to compare fat people to terrorists and to declare ‘war on obesity’), we need our troops to be as strong as possible. And that doesn’t mean conforming to some arbitrarily defined, absolutist notion of what ‘health’ is. To me, health is a matter of making autonomous choices, and having the resources necessary to inform those choices. Though we may all disagree on which behaviours are healthy or not, I think we can all agree that losing once-fervent supporters to the health meritocracy does not strengthen our numbers. Having an alternative that emphasizes good information, respectful practitioners, and a culture of individual sovereignty will.

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16 Comments

  1. deeleigh
    Posted September 18, 2009 at 9:02 am | Permalink

    This is SUCH a great explanation of HAES.

    You know, I’ve been saying similar things for a long time, but right now, I needed to hear them again. As you know, it’s been difficult dealing with the changes in my body in the last few years, and to feel good again, I need to stop sulking and start taking better care of myself.

    Thanks for reposting it.

  2. Posted September 18, 2009 at 9:17 am | Permalink

    I’ve been grappling with the cognitive dissonance myself — but it’s along the lines of “what is the bottom of my set point?” I’m not out to have a BMI in the “normal” range — but to find a spot of equilibrium that my appetite and nutritional and activity needs can settle in and make my life more comfortable and health issues more manageable. I don’t extrapolate to anyone else’s experience.

  3. Stacy
    Posted September 18, 2009 at 9:33 am | Permalink

    Hi. Enjoyed the post. Am struggling with what seem like some inherent contradictions in this overall line of reasoning.

    Namely you say: “given that there are precious few (read: NO) permanent, safe methods of fat reduction.” But later you say, about one person’s : “It might mean losing weight…”

    No matter how carefully you make the argument (and I can see you have been thoughtful and careful about it)…I don’t think FA/HAES can be so strident about saying there are NO PERMANENT SAFE WAYS to reduce fat but then also say but some people might need to [and, by implication, CAN] lose (even just a little bit of?) weight for health related reasons. I get that the focus is different – in mainstream society diet diet diet to conform to a beauty ideal is unrealistic and soul sucking in itself; whereas HAES weight/fat reduction might be a byproduct of an increased focus on health, mobility, and movement.

    But it belies the argument that permanent weight/fat loss is impossible. It seems more likely that the motivation and methods that may result in weight/fat loss, however much or little, have a huge impact on whether it is sustainable and/or permanent.

    • Posted September 18, 2009 at 12:24 pm | Permalink

      Good point, Stacy.

      I think what I meant to say is that intentional weight loss is pretty hard to come by. There’s never been a guaranteed way that will work for everybody — and you can see the evidence of this in some of the articles in my sidebar.

      However, some people genuinely exist (at least temporarily) at a weight that is higher than their body wants (i.e., than their set-point), and this could be due to an underlying medical condition, or, potentially an eating problem. For those people, dealing with the underlying problem may result in weight loss.

      Problem is — none of us know, at a glance, who these people are. Some people are just fat, and going to remain fat. Some people might pass for thin, but be genuinely “overweight,” according to their body’s design. It’s impossible for any of us to know who is who.

      The point is, chasing intentional weight loss is counterproductive. Even for those few people for whom it seems to be in the cards.

      I don’t actually think weight loss or fat loss is impossible for every single person — I just know that the many interventions and diets that have been tested for doing this have had dismal success rates. Because, presumably, not that many people are existing above their set-points due to issues that these interventions/diets address. (Because set-point is pretty tightly controlled by several different feedback loops and homeostatic controls. That said, it can go out of wack, but those tend to be exceptional cases. Say, the 5-20% of people who manage to lose weight on a typical weight loss diet.)

      Sorry I’m not more clear on this — I’ll give it some thought and likely post more later. I just woke up :)

  4. Posted September 18, 2009 at 10:52 am | Permalink

    Wow, one of the best things I’ve ever read about HAES/FA. It’s a relationship I struggle with, myself.

  5. meerkat
    Posted September 18, 2009 at 10:57 am | Permalink

    I think if I started playing in the park like I was 5 years old again, I would be arrested or committed to an asylum. Besides, all my few memories of sweat = fun are kind of tainted by the other kids’ hating my guts, or if adults were involved I now realize they were going easy on me because I was five and it turns out that I actually completely suck at tennis.

    • Posted September 18, 2009 at 1:14 pm | Permalink

      I wish they made play-parks designed for adults. Seriously. That’s the kind of moving I actually enjoy.

      I want a big fat playground. And no haterzzz allowed.

  6. Posted September 18, 2009 at 12:53 pm | Permalink

    “I don’t think FA/HAES can be so strident about saying there are NO PERMANENT SAFE WAYS to reduce fat but then also say but some people might need to [and, by implication, CAN] lose (even just a little bit of?) weight for health related reasons.”

    I guess I take it this way:

    1. We need to stop telling fatties they are wrong, and sick, and unhealthy, and just vile. (FA)

    2. If people want to pursue better health, they should not focus on weight. (FA/ HAES)

    3. Some people are temporarily under- or over-weight due to poor health practices. If these people improve health practices, their weight might change. (*might*) (HAES)

    Is that correct?

    • Posted September 18, 2009 at 1:06 pm | Permalink

      Yeah, that basically sums it up for me.

      The bottom line is, there really isn’t any proven, effective way to get wide swaths of people to lose weight predicably and permanently.

      Nevertheless, *some* people do genuinely lose weight, and keep it off long-term. Numbers in the literature range anywhere between 5-20%.

      I can’t help but think that those people were existing at a weight above their set-point, and that they probably would’ve lost weight permanently whether they dieted or followed a HAES approach.

      Does that make sense?

      What makes the important difference is: dieting purports to make all people lose weight, permanently. Because 80-95% of the people who engage in it do not lose weight permanently, dieting fails as an intervention. It fails to achieve its stated directive, and it also doesn’t seem to help people permanently pick up healthier eating/moving behaviours.

      Whereas HAES does not purport to do *anything* to a person’s weight. It purports to encourage healthier eating and moving. And while only a few people might lose weight, just like in dieting, HAES succeeds as an intervention — because the goal was to engage in healthier behaviours, not to lose weight, in the first place. Evidence has shown (in Linda Bacon’s study) that HAES does actually succeed in getting people to adopt healthier eating and moving behaviours that stick around for the long-term.

  7. Posted September 18, 2009 at 1:24 pm | Permalink

    Brilliant response!

    I am still getting my head around HOW to know if one is healthy? I have grown up thinking to the extent one is fat one is unhealthy. Isn’t that funny? Or no it’s not. It’s exactly what you’re talking about here.

    I always get good readings at the doctors’ office (pulse, blood pressure), etc. And of course I’m very active and eat well (I think). But I don’t really know how to assess my health much more than that (or if I even should).

    • Posted September 18, 2009 at 1:31 pm | Permalink

      I try to think of it in terms of there being more “direct” measures of health, and weight is a much more “indirect” measure.

      I mean, getting your blood pressure and your heart rate checked tells you something *directly* about how your heart and blood vessels are functioning. In comparison, your weight? …Doesn’t really have a whole lot to say, directly, about your heart. It just engenders a lot of wild speculation about what’s actually going on under the hood.

      Your cholesterol, your blood glucose, your thyroid hormones — more direct measures of how your endocrine system is working.

      Not that I want to encourage “healthism” or anything like it, but for those people who are concerned about their health indices, and who tend to inordinantly focus on weight as a result of those concerns, it’s likely much more productive and *accurate* to shift that concern onto actual, direct measures of your body’s functioning. Rather than what it looks like.

      It’s like looking at the size of a car to determine how well its engine is running. Just doesn’t make a whole lot of sense. Pop open the hood and get some *real* answers, for crying out loud. Stop kicking the tires.

  8. Robin
    Posted September 18, 2009 at 2:59 pm | Permalink

    Thanks so much for this post. At 42, with inherited arthritic knees, I’ve been putting off seeking treatment for them. I’ve had a couple of minor surgeries on each knee in the last few years and have been dealing with a new flare up for over a month. I know if I were a thin person, I would have been on the phone weeks ago getting an appointment with the orthopedist. Thanks to blogs like yours, I was able to be straightforward with the doctor last year when he mentioned that weight loss would help. I told him I’d tried many times, only to regain the weight back and more and that I was mainly focused on maintaining my weight and staying active. Even so, I feel like a failure that my knees have flared up again and that my weight is to blame. I’m even paranoid that I would be denied something like knee replacement due to my weight. I think about all the health problems and preventive care (annual exams) that we put off due to fear of the scale in the doctor’s waiting room and wonder how much that has to do with some of the studies that correlate obesity with health problems.

  9. Lisa
    Posted September 19, 2009 at 5:13 pm | Permalink

    Oh, such a great post! I think you summed up HAES beatifully!

    For me, HAES is about eating well, breaking a sweat on a regular basis and (most importantly) **accepting that my body will be the size it wants to be given my genes and my eating/exercise history**

    It really comes down to trusting that your body really honest-to-god knows what it is doing, and you screw with it at your peril.

    Thanks so so much for re-posting this!!

  10. Posted November 16, 2009 at 7:08 pm | Permalink

    Very nicely put. You covered all the bases (or all the bases I’m aware of) and did so in a way that explained HAES in a rational, fair-minded way. My wife and I have been discussing HAES of late and she does not subscribe to how I was explaining it, but I’m curious if she will be more attuned to your explanation.

    This is a great primer for HAES. I will be linking to it often.

    Peace,
    Shannon

  11. Posted July 7, 2010 at 8:52 pm | Permalink

    This comment is super duper late, but I had to tell you how brilliant this post is. I’ve linked to this so many times because it so perfectly explains what HAES is and what HAES isn’t.

  12. Posted September 3, 2010 at 11:04 am | Permalink

    Excellent! I’m an ally of the fat acceptance movement but also this was so helpful for me to read, just for myself, and I plan to come back and read it again. Thanks.

3 Trackbacks

  • By New to Fat Acceptance? « on August 30, 2010 at 8:30 pm

    [...] Health at Every Size: choice or coercion? at Fat Nutritionist By far the most comprehensive explanation I’ve read of what HAES really means. [...]

  • By Another HAES Quote | Living ~400lbs on September 1, 2010 at 10:04 am

    [...] HAES Quote Posted on September 1, 2010 by Living 400lbs| Leave a comment This quote is from Michelle, aka The Fat Nutritionist.  Links within the quote were added by me. [D]ieting purports to make [...]

  • By I Need More Categories | Mighty Cupcake on November 4, 2010 at 10:12 am

    [...] One last thing, this blog entry from The Fat Nutritionist, which my friend Sydney directed me to, is another great read to help you understand Health at Every Size and to point out a fallacy people often have about HAES: “Health at Every Size: Choice or Coercion” [...]

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